Utilization Management
Case Management
Disease Management
Care Concierge
Live. Well
Encore Care offers a number of products and services that can be customized to meet the needs of any specific employer group:
Utilization Management
When claims are managed effectively, payors and employers save money while patients receive more efficient and effective care. Encore Care provides a full range of medical management programs that cover each stage of the claims process:
- Pre-certification of inpatient and outpatient services determines medical necessity of a claim
- Concurrent Review collects data during treatment to support continued services
- Retrospective Review plans appropriate patient discharge and, when needed, evaluates medical necessity after services have been rendered
Our Utilization Management system is also designed to alert employers to the possibility of excess claims among employees.
Case Management
Patients who experience injuries or certain acute illnesses often need professional oversight to efficiently navigate recovery. When specific diagnoses are reported among members, our team of RNs go to work to manage their short-term or catastrophic cases. These members are monitored and their treatment is managed to ensure overall patient care and reduce plan cost. The service includes special programs for High Risk Pregnancy, In Step Hip Replacement, and Organ Transplant.
Disease Management
There are certain conditions for which patient self-care is significant. When members with these conditions go unassisted, they often move from being moderate risk individuals to being high risk individuals which places a strain on overall health dollars.
Our nurses utilize a wide range of tools to identify patients with the highest risk to future cost. Then, they reach out to these individuals with a number of practices to accomplish risk reversal including:
- Individualized care plan establishment and goal setting
- Coordination with physicians and ancillary providers
- Behavior modification programs
- Nutrition and exercise strategies
- Healthy lifestyle coaching and monitoring
Care Concierge
When employees truly understand their health plans, they are more likely to take full advantage of them and live healthier lives. The Care Concierge service can be used with any health plan and consists of a group of nurses, benefit specialists, and case managers who provide employees with professional guidance in a number of areas including:
- Claims resolutions and disputes
- Plan language comprehension
- Instruction on obtaining letters of medical necessity
- Network steerage and negotiations
- Pre-certification issues
- Steps for obtaining ancillary services
- Explanation of EOB's
- Assistance with specialty drug issues
Live. Well
When overall employee health improves, employers see a reduction in health costs and an increase in productivity. Encore Care specializes in integrating health and fitness into the culture of business, and our Live. Well programs are so flexible that any company can tailor its terms to their specific needs. Employees enjoy greater health and quality of life, while employers benefit from higher staff retention, reduced absenteeism, and insurance policy reductions.
Live. Well include:
- Employee Health Assessments to include height, weight, BMI, blood pressure, blood sugar & cholesterol screenings
- Targeted monthly wellness & nutrition newsletters
- Interactive website accessible to all employees to promote motivate, educate and provide tools to help employees
- Annual health fair at employer's location with various free tests and education material (with or without employer incentives)
- Lunch & learn sessions (2 a year)
- Discounts with local exercise facilities
To learn more about Encore Care's products and services, simply contact Encore Health Network at 1-800-574-8180.